What is the treatment for paronychia?

Treatment for Paronychia

The treatment of paronychia should include warm soaks with or without Burow solution or 1% acetic acid, followed by topical antibiotics with or without topical steroids, and drainage if an abscess is present. 1

Classification and Treatment Approach

Paronychia is an inflammatory condition affecting the nail folds that can be classified as either acute or chronic:

Acute Paronychia Treatment

1. First-line therapy:

   • Warm soaks with or without Burow solution or 1% acetic acid 1
   • Topical povidone iodine 2% or topical antibiotics to reduce infection risk 2, 3
   • Topical corticosteroids for inflammation 2, 3

2. For abscess formation:

   • Drainage is mandatory - options include:
     • Needle aspiration
     • Incision and drainage
     • Partial nail avulsion 3, 1
   • Oral antibiotics are usually unnecessary if adequate drainage is achieved, except in immunocompromised patients or severe infections 1

3. For moderate to severe cases:

   • Consider partial nail avulsion 2, 3
   • For recurrent cases, partial nail avulsion followed by phenolization is recommended 3

Chronic Paronychia Treatment

1. Primary approach:

   • Identify and eliminate irritant exposure 1, 4
   • Topical steroids or calcineurin inhibitors for inflammation 1, 4
   • Antifungal treatment if Candida infection is present 4, 5

2. For recalcitrant cases:

   • Surgical options may include:
     • En bloc excision of the proximal nail fold
     • Eponychial marsupialization 4
     • Swiss roll technique for severe cases 6

Treatment by Severity (Based on CTCAE v5.0) 2

Grade 1 (Mild)

• Continue monitoring
• Topical povidone iodine 2%, topical antibiotics/corticosteroids
• Reassess after 2 weeks

Grade 2 (Moderate)

• Topical povidone iodine 2%, topical beta-blocking agents, topical antibiotics and corticosteroids
• Consider oral antibiotics
• Reassess after 2 weeks

Grade ≥3 (Severe)

• Interrupt causative agents if applicable
• Obtain bacterial/viral/fungal cultures
• Topical treatments as above
• Oral antibiotics
• Consider partial nail avulsion
• Reassess after 2 weeks

Prevention Strategies

• Gentle skin care
• Avoid trauma to nails and cuticles
• Wear comfortable shoes and gloves while cleaning
• Avoid biting nails or cutting nails too short
• Apply daily emollients to cuticles and periungual tissues
• Keep hands and feet dry 2, 3

Important Considerations

• Secondary infections with bacteria or fungi are common and may require specific antimicrobial therapy 1, 4
• Treatment of chronic paronychia may take weeks to months 1
• Patient education is crucial to prevent recurrence 1
• For paronychia associated with anticancer agents (particularly EGFR inhibitors), treatment follows similar principles but may require dose interruption of the causative medication in severe cases 2

Common Pitfalls to Avoid

• Failing to drain an abscess when present
• Treating with oral antibiotics alone without addressing the underlying cause
• Not identifying and eliminating irritants in chronic paronychia
• Overlooking fungal infection in chronic cases
• Neglecting preventive measures, which are cornerstone of therapy especially for chronic paronychia 1, 4